Covid-19 Blog 3: Update
Myth-busting and Viral Facts
I have been writing about Covid-19 for the past 2 months and since that time it has grown from something interesting a half a world away to a global pandemic with New York as the current epicenter. As our knowledge and dissemination of information has grown tremendously, unfortunately, the rate of MIS-information also seems to grow.
In science (and medicine) there is a golden rule – “All facts have a half-life”. This means that things we know to be “facts” today over time are eventually changed or are disproven when a larger general body of knowledge is discovered. That’s why treatment protocols, from cancer to chronic diseases, not only sometimes change but sometimes head in a completely opposite direction from the dogma of the past. Thus, it is always dangerous to declare something in medicine a fact. In “fact”, things mentioned in my first blog, factual at the time, have already proven to be outdated. More on these specifics as we go along.
The corollary to the golden rule above is playing out equally in magnitude in the case of Covid-19. That rule/quote (From C.H. Spurgeon) – “A lie will go around the world while the truth is still putting its boots on.” Well as Bono says…It’s time to get our boots on (and start spreading the truth).
First and foremost, let’s get this out of the way. Covid-19 comes from a virus. It’s not a hoax, it’s not a conspiracy and it is not from the rollout of the 5-G cellular network. The virus was not created in a Chinese or Russian bioterrorism lab, nor was it brought to central China by a CIA agent. All of these claims are ubiquitous and repeating them is downright dangerous as it prevents us from being prepared from this and future threats.
The virus, Sars-Cov-2, we now definitively know did not come from the sources above or from snakes, it came from bats in the central (Wuhan Provence) of China. How do we know this? First, bats are a known vector for a large number of “human” viruses including hantavirus, Ebola, and SARS. Coronaviruses and SARS have a very muted clinical response in bats, so they carry it without it affecting them. The SARS epidemic (also a coronavirus) came from these same bats. In both instances there was a single case of transmission – from one bat to one human. We know this because when the RNA of the virus was tested, it is clear there was initially a single strain, that has, once in the human vector, subsequently mutated (more below). If there were multiple bats infecting multiple humans, there would be many more strains from the get-go. To lend further credence to this is that smart scientists have not only known that bats would be the origin of this type of pandemic – they predicted it a decade ago. Not only did they predict bat-human transmission, but they predicted the “hotspot” where it would start. The illustration below and this link (watch it, its short and fascinating), is to a TED talk from 2009. In this talk a scientist named Peter Daszak said “We have shown that bats are the main reservoir of SARS and people eat bats all over Asia.” He then produced this Heat Map declaring exactly where the next global outbreak would start. The area in red on the right is centered in Wuhan China.
2009 prediction of location of origin of the next Pandemic
Social Distancing: Flattening the curve and its Costs
We are a couple weeks into the great social distancing experiment. I say experiment because we are using a proven but imperfect process to save lives, at great economic and social costs. It is very easy to get political or biased and say that “every life matters, regardless of cost” or “the magnitude of the costs outweigh the benefits and we do not respond to other crises this way”. It is the toughest of calls our world leaders and we as individuals have to make to walk this very serious balance.
When looking at our experiment, we need to start with what the goal is – saving lives; and look at both, how it does this and how effective it is. Social distancing saves lives by not stopping but SLOWING the spread, so our medical resources, namely ICU beds and ventilators, aren’t overwhelmed and people who would otherwise live, die because they cannot get life saving measures. With the rapid advancement in testing and treatment, if people get infected at a later date, their response to the virus may be less severe with prompt and new forms of treatment.
So if we are grading the experiment, how are we doing on this score? Rather well actually. An epidemiologist and professor at the Imperial College of London predicted if we had not changed social behavior at all across the world then 7 billion people would be infected with Sars-Cov-2 and 40 million would have DIED. Woe! Furthermore, if we just chose to shelter to susceptible (elderly and people with co-morbidities) then we only would have cut the number in half to 20 million deaths. That is deaths this YEAR.
Although its early, current predications based on our (restricted) activity reduce this 40 million number down to 1.3 million. Still a HUGE number, but obviously, sheltering in place is having a substantial global impact.
This cure is not cheap. SARS back in 2009 killed 800 people. The estimated economic impact of SARS during its one winter of infection was $50 BILLION. As large of a number as that is, with our response to this virus, $50 billion is likely the economic impact in Dallas-Fort Worth alone, not the entire world. Indeed, the economists who are looking at the other side of the experiment, lose all financial predictive ability beyond 60 days of shelter in place. They do predict that every day beyond 60 provides further and further economic calamity. Restaurants, local business, landlords, the 10’s of millions of unemployed with credit card bills and mortgages, all face a scary deadline. Of note, 60 days puts us somewhere near Memorial Day. Shelter in place orders by the governor of Virginia already are to extend through June 10th, well past this 60-day moment. Hopes for a “V-shaped” recovery dwindle by the day as we approach that.
Just as there is an economic cost, there are other costs as well. Child abuse rates are going up. Suicides which always increase in a recession are spiking quickly. Stories of people dying from curable conditions – like a simple, treatable heart attack – because they are lacking access to medical care due to hospital beds being taken up by Covid victims, are happening with increased frequency. Also, to prevent the “second wave” (see below) we need a certain percentage of the population to have had the virus and get immune so they cannot spread it – a concept called “herd immunity”, and social distancing slows this phenomenon from happening.
So, what is the right call? (To misquote Plato) I think I know more than everyone else because I know that I know nothing. In other words, I have no idea. We have to do our best and put our faith in God, our leaders and ourselves that we will all do the right thing together, during the experiment, and after.
Masks: The fact that had a 2-month half-life
In both my February and March blog, I recommended that masks, even N95 will not prevent you from getting Covid-19, it will just keep those who have it from spreading it.
Just this week, the CDC has recommended that we go beyond social distancing and wear masks when in public. Was I wrong? Well it turns out mostly no. The recommendation is to keep you from infecting others. The expansion of it takes into account that there is a large number of asymptomatic carriers that are still infectious even though they have no fever or cough. So, it is still to prevent others from infection.
There may be a slight benefit of wearing a mask, beyond particle filtration, but due to increase in humidification of your airway. A dry airway is a damaged airway and a crack to let the virus in. That being said, there is a debate if wearing a mask causes you to touch your face less because it is covered, or more from fidgeting with the fit and thus inadvertently infecting yourself or giving a false sense of safety.
Of note if you are wearing a covering that is not a disposable mask, (cloth, bandana, scarf) wash it daily. The virus lives on surfaces including cotton and wool so use a detergent to kill it. Disposable masks are just that disposable. From my days as an anesthesiologist I can tell you that the Texas Department of Health and OSHA who inspect hospitals love to cite and fine hospitals for employees who leave a sterile area and just take their mask down and leave it around their neck instead of throwing it away. If a mask is stopping a particle or droplet vector, it becomes a vector.
My Allergies are killing me! Or is it just Covid-19
If it were a joking matter, I would say well played Covid. How perfect to infect us right at the end of cold and flu season (is it cold/flu or is it Covid?) and right at the start of spring allergy season (Cough Cough…it’s just my allergies don’t mind me…)
Being a 23 year Texas “native” (I did get here as quick as I could), I have always had a fondness for April, great (I don’t mind the rainy) weather, vast fields of blue bonnets, and that blanket of yellow pollen that covers your car when you leave it outside for a few hours (well not so much that one). The symptoms of a mild case of Covid vs allergies are tough to distinguish.
Do acute allergies put you at more risk? And What should you do to treat them.
“Allergies” are an immune response to a foreign body that enters through your skin, respiratory tract or gut. These allergens trigger the same immune system used to fight diseases (from viruses to cancer) to ramp up and fight this foreign invader. In trying not to go too far into a master class on immunology (we will do that in a future blog) some key principles in allergy/immunology are important.
There are two sides to your immune system, the innate (instant, nonspecific response) and the adaptive (slower, specific response). People who have a severe response (and end up in the hospital or ICU) to Covid have this because the virus tricks them to stay on the innate side. On this side, in an attempt to cut the number of invaders, the white blood cells release powerful substances known as free radicals (and compounds in the so called cytokine storm you may have heard about) that damage not only the invaders but also our healthy lung tissue. The natural hand off from innate, nonspecific to the focused, adaptive side is simply impaired. Allergies (since you have been exposed to them before) uses that focused adaptive immune side, a side you need to finish off the infection. So, do acute allergies increase risk? Probably yes for two reasons. One you are touching your face more with a runny nose or watery eyes for allergies, thus introducing a potential contaminant you have touched into your body. Second, to use a military analogy, your immune system is already fighting a battle on one front, so your troops are divided and less able to mount a full-scale attack against the invading virus.
Thankfully the treatment /hack to boost immunity work for both Covid and allergies. I mentioned in previous blogs, Thymosin Alpha 1, Vitamin C and Zinc (as well as B and D vitamins). All of these help the transition from the innate to adaptive immune response. They also all help the adaptive immune response to find balance and heal quicker to get your forces back ready for action.
Prescription grade Zinc Lozenges
If allergies are a problem, I would suggest our supplement, Allervite which has Vitamin C and Quercetin, as well as an allergy IV. Also adding Reishi mushroom to your coffee might be a game changer.
Covid Testing: Where we are April 2020
A big part of the reason we are not on top of this outbreak is due to the state of testing circa April 2020. This is not a criticism of our, or any government response. We simply didn’t have the tools or supplies to be able to test on a mass scale the right way. The government has fast tracked new techniques on an antiquated infectious testing system to add in private laboratories to the overburdened state-run health department labs and also enlisted private medical technology companies to innovate quickly on new types of testing. We will really start reaping the benefits of all this month.
As of last week, we had one way to test for the virus. Using a technology called PCR, providers would swab a patient mouth and nose and would send this swab to a laboratory that would look for the specific genetic signature of the virus. The machines that do this didn’t exist outside of research labs a decade ago and have slowly made their way into private labs across the country. Due to the relatively low penetrance of these machines compared to machines that run blood and urine for simple chemistries, clinical operational efficiencies like laboratory/device throughput and quick turnaround time are difficult to achieve when this technology is scaled to an entire country of 375 million people. Our Formula Wellness clinical experience testing patients in LabCorp – the largest lab company in the world, is us seeing a turnaround time of around 10 days from sample to result by the lab. In 10 days, someone is pretty much over the disease, in the ICU or has infected about 100 . Clearly not an optimal solution.
As more laboratories come online with this technology, and more testing kits become available, the turnaround time will continue to fall. Indeed, the FDA approved this same PCR technology to be done in a doctor’s office on a machine made by Abbott labs, and the result will be obtained in 15 minutes. This will begin to have the serious impact we need for clinical decision making – being able to tell a patient RIGHT AWAY that they currently have the virus and to quarantine themselves and not infect others. Unfortunately, there is a limited number of these machines in doctors’ offices and probably won’t be to sufficient scale until fall.
Even once ramped up this test tells one thing – do you currently have (and are shedding) the virus. Helpful information no doubt, but it doesn’t tell us if you have had it in the past and where in the span you are – day 1 or day 14. To do this we need to be able to not just test for the presence of genetic material (PCR testing) but test for antibodies to the virus (Immunoglobin Testing). Immunoglobins are the specific antibodies that our body produces in the adaptive immune response to fully eliminate the virus and keep on surveillance for future reinfection. There are two relevant types in viral infection: IgM, which are our bodies quick powerful first line antibody response, and IgG which is the definitive and “memory” response. The IgM peak in the first 10 days and then disappear in a 3-6 weeks. The IgG slowly develop around day 12 and stay – potentially for years. Thus, if we can test for the presence of IgG, we can not only tell who is infected but who is safe to return to work, and get the economy moving again quicker.
Luckily this testing is here in small scale and should be in large scale in a month. We at Formula Wellness have the first generation of these point of care antibody kits that are under FDA review and have begun testing our patients.
With these testing breakthroughs we are on the cusp of turning the corner in both the health and economic crisis we are in. An instant point of care (POC) test for the gene of the virus (PCR) and instant antibody test will tell us who is infected, how long they have had it, and when they can return to the workforce. If there is one key factor in flattening the health curve AND economic recession/depression curve its rapid testing/resulting that gets us back to work.
Mild vs Severe Covid-19
The news continues to report the same thing. The elderly and people with coexisting illness (co-morbidities) are at the greatest risk. Yet we hear anecdotes of 30-year-olds on ventilators and even dying. What gives? There are in my opinion, 2 probable reasons. First, I think the age thing is overstated. I think that co-morbidities trumps age in this disease. Now, it happens to be a fact that as we age, we tend to have a higher incidence of co-morbidities – high blood pressure, diabetes, heart disease…but if you control for these, age will be less of a factor. I think many of the severe cases seen in the young and “healthy” are actually cases of infection in people who don’t know they have a comorbidity. If you never see the doctor, if you don’t take your blood pressure or know what your fasting blood sugar is, you aren’t healthy – you just don’t know if you are healthy or comorbid. Many people may be in a higher risk category and not know it. See the blog post in January on the healthy user effect and how flu vaccines demonstrate the pleiotropic effects of knowing your numbers.
Second, as mentioned previously, this virus enters cells through a receptor on a cell called the ACE2 receptor. It is more than a possibility that a percentage of the population have a genetic variation that causes them to have more of this receptor type on their cells – thus more entry points for the virus. So, these individuals that we have not previously identified yet are genetically predisposed for a more severe response. This is inherently proven by the inclusion criteria of high blood pressure individuals being in the higher risk group – people with high blood pressure develop more of these ACE2 receptors on their cells and are more likely to be in the severe group.
Covid Treatment: Circa April 2020
The FDA which was not designed to be an organization to fast track drugs and therapies in a crisis is doing a decent job of advancing the ball. By now all have heard of the use of 2 drugs – Hydroxychloroquine and Zithromax as a combination therapy to help slow the virus from replicating (reproducing) in the body as well as making it harder for it to enter cells. Astute readers will note that in a previous blog I mentioned that antibiotics do not help since this is a virus – and Zithromax is one of the most commonly prescribed antibiotics. Well as it turns out, Zithromax has a unique method of action and it has anti-viral properties as well as antibacterial properties. It is not effective on its own but in combination with HCQ, seems to cut the severity greatly. Right now, HCQ is in extremely short supply and limited to hospitals, by this summer supplies will be abundant but right now, it is not.
In addition to these two old school drugs, the oldest of school Vitamin C and Zinc are proving effective. Severe ICU cases are being treated with IV infusions of vitamin C with good success. The leading virologist in the world on Coronaviruses suggests that zinc – especially in the form of lozenges, decrease the viral load, helping the body’s immune system get on top of the infection. It is why we continue to offer and suggest to our patients to do our prescription strength Zinc Troches (lozenges) or get our super immune IV’s.
Viral Mutation and A Scary Autumn 2020
Sars-Cov-2 is an RNA virus. RNA viruses, unlike their DNA virus counterparts, are inherently more likely to mutate. DNA viruses have 2 matching strands of genetic material that have to fit together to make a pair. An RNA virus has just one strand and does not have a control-check mechanism to see if it has changed. This strand is made up of units called “bases” and if you change one base it is a mutation. Often mutations, especially those low in number, cause no change or effect. Mutations in particularly sensitive areas can be a good thing – making the virus weaker or making it harder for it to interact and get inside of a human cell. Sometimes though, mutations, particular those known as “mis-sense” mutations can change the outer coat of a virus, making it unrecognizable to our adaptive immune system and therefore making a previous exposure/immunity or vaccine, worthless.
This coronavirus is a particularly large virus. The common cold virus (Rhinovirus) and even viruses like HIV are around 10,000 bases in length. This coronavirus is over 3 times that size, greater than 30,000 bases in length, thus there is a lot more points for a mutation to appear. This is in part why we are seeing a mutation rate in this virus that is 20% faster than most other RNA viruses and 1000x faster than the flu virus and 36,000x faster than the measles virus.
What does all of this increased frequency of mutations mean? Well as mentioned above it could be a good thing in that many of the mutations may make the virus weaker. However, we are ultimately going to rely on enough individuals getting the virus and developing long term immunity, or a vaccine that induces long term immunity, but if the virus changes enough, then we will no longer recognize it and we are starting over again. Indeed all of our economy busting, shelter in place, strategies are predicated on a slowed infection rate amongst the world population to not overwhelm, while we travel on our way toward herd immunity – a level of community wide immunity where so many people have had it that when it comes back around, they cannot get re-infected and thus infect the few who have not had it. If because of mutation, we are once again susceptible we are back to square one – and this time with less economic firepower to handle another economic stop down – we simply don’t have trillions more to shell out for more months of shelter in place next year.
There will be a decrease in infections this summer. Most viruses, and it appears from the lower amount of equatorial spread, this virus in particular will not survive much in North America in the summer. However, with fall will come another round and those that don’t have immunity or have ineffective immunity will be susceptible. In the fall-winter, unlike now, shelter in place won’t be an option. SARS killed 800 and cost $50 billion, Covid-19 will kill? ( one million?) and cost trillions. There is a finite economic response and we simply won’t have the firepower for another round of trillions in expense. As difficult as this situation is now, without improvements in testing and treatment, many more will die in the second round in the fall of 2020, and the economic toll will be nothing short of a global depression.
This is not to scare everyone. We have a path forward. We are drinking from a proverbial fire hose with information on testing, oral drug therapies, IV drug therapies, Vaccines, “convalescent” plasma transfusions, stem cell/exosome treatments. There is a lot of work to do in the scientific and medical community to get us prepared for fall 2020. This may be not in most people’s mindset right now as we are still in the heart of phase 1. We have to listen to our leaders and get through this phase quick. We need to open our economy. We need to deploy and have ready better testing for the fall. We need everyone to take seriously “hacks” like Vitamin C and Zinc (and I would add Thymosin Alpha 1, exercise and nutrtion) to optimize our immune system. We need vaccines and drug therapies in better supply.
All of this will happen. I am surprised and elated at the response we as a global community have accomplished to date and am optimistic, we will respond even better the second go around. Key to that though is knowledge and blasting away at misinformation and untruths. It is the reason why I am writing overly long blog posts in an attempt to educate – and correct my own posts when their scientific half-lives have expired. It is everyone else’s job to disseminate the information and continue to be considerate to others in terms of spreading the virus, as well as being supportive of businesses that need it to get the economy churning again, and lastly to individuals in need of human connection in a time of isolation. Economic peril in recessions and depressions does beget further medical emergencies and preventable deaths – from treatable illness to suicide and abuse. We all have a role to play, and that goes well beyond the expiration of our time we are sheltered in place.
As always, Stay well,